Healthcare Provider Details

I. General information

NPI: 1578848586
Provider Name (Legal Business Name): SUSANNAH OKUTORO-KETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WABASHA ST S
SAINT PAUL MN
55107-1805
US

IV. Provider business mailing address

205 WABASHA ST S
SAINT PAUL MN
55107-1805
US

V. Phone/Fax

Practice location:
  • Phone: 651-293-8191
  • Fax:
Mailing address:
  • Phone: 651-293-8191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR-219830-5
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001399
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: